Now, I do understand that because orthopaedics is very competitive and so many don't have 20 programs on their list. When you are making your list, you may want to take way all of the bias that you may have based on "rankings", what people have said, and what the different forums have said. You need to try to look at these programs in a vacuum that is influenced only by your own experience.
Things that may become important are : (these are not in any particular order)
1. location
2. learning environment
3. resident "personality"
4. program "personality"
5. research opportunity
6. faculty / resident relationship
7. operative experience
8. program balance

So, let's look at each of these an how they relate to you and your personality.

LOCATION
I think location is one very important factor. Now, most of the ambitious students always want to go to the best program regardless of location. I am gunner hear me roar.

Well, location does really become important in you underlying happiness. Yes, I said it, your HAPPINESS. Look at what size cities and locations in the country may you happy. Are you small town or big city, east coast or west coast, northern or southern? These things should be taken into consideration. You need to fit into your environment outside of work as well as inside.

LEARNING ENVIRONMENT
When you look at the department, what is the learning environment? Do they have a schedule of lectures? Who gives the lectures? How often are the lectures? Do they teach to the OITE or Boards? What is the board pass rate?

I bring this up because there are some programs that have a great learning environment. There are scheduled lectures, the faculty (all) is involved, the residents give lectures with faculty assistance and the attendance lectures is a requirement. There are other programs that lectures are given mostly by residents (lectures passed from resident to resident), there is very little faculty input, and attendance is sketchy. A lot of programs like to promote the OITE as a marker of how good the programs didactic schedule is. I would beg to differ. In some instances, the program trains its residents for the exam. Be careful, I do feel it is important; but by itself, it means nothing. I do feel the board pass rate is much more important.

RESIDENT PERSONALITY
This is the gut feeling part of the rank list. Will you get along with you peers? I call it the "I could sit down and have a beer with this person" factor. Does the general resident personality fit yours?

PROGRAM PERSONALITY
Every program has a personality, an underlying undercurrent to the program. This is usually dictated by the program chairman/residency director.

Is it a "malignant" program or more "benign"? This is the conversations with other applicants and residents from the program come into play. Can you tolerate the malignant programs? Do you respond to that type of instruction? Can you flourish in a more benign environment, or do you need more encouragement?

RESEARCH OPPORTUNITY
This is something for those who are looking for a future in the academic arena. Are there opportunities for research? How many publications do the residents (not faculty) put out each year? If you want to move up in the academic world and want a high profile fellowship that will set you up for increasing you input in the AAOS etc., then this will be an important factor; if you are going into private practice, probably not.

FACULTY / RESIDENT RELATIONSHIP
This is like the program personality, but I feel it is important to your underlying happiness. How do the faculty and residents interact. Is there supervision with the opportunity for you own growth and input or is it a dictatorship? Do you operate or observe? Do the faculty welcome questions or are not available for questions? As a chief resident, do you have the opportunity to make some decisions with supervision; or as an intern, you make the decisions without supervision?

I feel this is extremely important. There need to be supervision or guidance for the residence growth. If no supervision is given early, you will develop bad habits, like learning golf on your own. The faculty and upper level residents need to help the lower level residents develop good habits to prevent errors. On the other hand, there needs to be a point where you make a decision. This is a process that needs to be fostered within the program helping you mature from a grunt to a chief.

OPERATIVE EXPERIENCE
This is something that most people applying look at an relish. You must beware of programs that operate a lot early. Most applicants love this in a program. But, remember this YOU DON'T COME INTO RESIDENCY KNOWING HOW TO OPERATE. So, operating a lot early is a double edge sword. Yes, you will become more proficient earlier; but, the most important part of the outcomes in operations is proper patient selection. So, operation early is great, but should be offset with a lot of supervision and appropriate clinic experience.

PROGRAM BALANCE
Is the program balanced? Well, most programs are not. They tend to be heavy in some areas and weak in others. So, how do you decide? The question then is, what is the program doing to make the program more balanced? Have they added a rotation at another hospital? Are they adding faculty? These are things to look for in a program. Another indication of how a program is doing is looking at what fellowships are people doing and why they have chosen that specialty. If they are going into a fellowship because of an interest, this is not a negative and may indicate that this is an area influenced by the faculty (people tend to like areas where they have had a good experience). If they go into an area because they feel weak in that area, this is a negative.

In the end, making your rank list comes down to you gut feeling. But, I think you should look at number of factors that will make you happy in the end. The happier you are, the more likely you will be successful in you chosen field.