Congenital talipes equinovarus (clubfoot) is one of the most common congenital malformations; it affects 1–3 in 1000 live births and occurs twice as often in male fetuses.1Werler M.M. Yazdy M.M. Mitchell A.A. et al.Descriptive epidemiology of idiopathic clubfoot.Am J Med Genet A. 2013; 161A: 1569-1578Crossref PubMed Scopus (63) Google Scholar,2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar It can be unilateral (30–40%) or bilateral (60–70%) and can be either an isolated malformation (50–70%) or complex and associated with other structural or genetic anomalies (30–50%).2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar, 3Viaris de le Segno B. Gruchy N. Bronfen C. et al.Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center.J Clin Ultrasound. 2016; 44: 100-105Crossref PubMed Scopus (15) Google Scholar, 4Bakalis S. Sairam S. Homfray T. Harrington K. Nicolaides K. Thilaganathan B. Outcome of antenatally diagnosed talipes equinovarus in an unselected obstetric population.Ultrasound Obstet Gynecol. 2002; 20: 226-229Crossref PubMed Scopus (50) Google Scholar, 5Canto M.J. Cano S. Palau J. Ojeda F. Prenatal diagnosis of clubfoot in low-risk population: associated anomalies and long-term outcome.Prenat Diagn. 2008; 28: 343-346Crossref PubMed Scopus (32) Google Scholar, 6Offerdal K. Jebens N. Blaas H.G. Eik-Nes S.H. Prenatal ultrasound detection of talipes equinovarus in a non-selected population of 49 314 deliveries in Norway.Ultrasound Obstet Gynecol. 2007; 30: 838-844Crossref PubMed Scopus (47) Google Scholar, 7Nemec U. Nemec S.F. Kasprian G. et al.Clubfeet and associated abnormalities on fetal magnetic resonance imaging.Prenat Diagn. 2012; 32: 822-828PubMed Google Scholar Clubfoot is a structural deformity of the foot and ankle with hindfoot equinus (plantar flexion), varus of the heel (inward rotation), supination, and adduction of the forefoot (plantar cavus).8Bar-Hava I. Bronshtein M. Orvieto R. Shalev Y. Stal S. Ben-Rafael Z. Caution: prenatal clubfoot can be both a transient and a late-onset phenomenon.Prenat Diagn. 1997; 17: 457-460Crossref PubMed Scopus (30) Google Scholar A diagnosis of clubfoot can be made as early as 13 weeks of gestation; 85% of diagnoses are made between 13 and 23 weeks of gestation.2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar,7Nemec U. Nemec S.F. Kasprian G. et al.Clubfeet and associated abnormalities on fetal magnetic resonance imaging.Prenat Diagn. 2012; 32: 822-828PubMed Google Scholar,9Keret D. Ezra E. Lokiec F. Hayek S. Segev E. Wientroub S. Efficacy of prenatal ultrasonography in confirmed club foot.J Bone Joint Surg Br. 2002; 84: 1015-1019Crossref PubMed Scopus (53) Google Scholar Before 13 weeks of gestation, a transient clubfoot position can be present as part of normal development.10Bogers H. Rifouna M.S. Cohen-Overbeek T.E. et al.First trimester physiological development of the fetal foot position using three-dimensional ultrasound in virtual reality.J Obstet Gynaecol Res. 2019; 45: 280-288Crossref PubMed Scopus (10) Google Scholar To diagnose clubfoot, one must visualize both the tibia and fibula in the same plane as the sole of the foot (Figures 1 and 2). Abnormal positioning persists over the duration of the scan.2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar,11Benacerraf B.R. Frigoletto F.D. Prenatal ultrasound diagnosis of clubfoot.Radiology. 1985; 155: 211-213Crossref PubMed Scopus (23) Google Scholar It is important to visualize the foot away from the uterine wall to avoid the false appearance of a clubfoot from fetal positioning. In all, 70–75% of isolated cases are confirmed at delivery, with a reported false-positive rate of 10–20%; 5–13% are confirmed as complex postnatally.2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar,12Toufaily M.H. Westgate M.N. Holmes L.B. Congenital talipes equinovarus: frequency of associated malformations not identified by prenatal ultrasound.Prenat Diagn. 2015; 35: 254-257Crossref PubMed Scopus (12) Google Scholar,13Lauson S. Alvarez C. Patel M.S. Langlois S. Outcome of prenatally diagnosed isolated clubfoot.Ultrasound Obstet Gynecol. 2010; 35: 708-714PubMed Google ScholarFigure 2View of the foot and legShow full captionFlat view of the foot is seen in the same plane as the lower leg. The lower leg should not be seen when the bottom of the foot is being viewed.SMFM Fetal Anomalies Consult Series #2. Am J Obstet Gynecol 2019.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Flat view of the foot is seen in the same plane as the lower leg. The lower leg should not be seen when the bottom of the foot is being viewed. SMFM Fetal Anomalies Consult Series #2. Am J Obstet Gynecol 2019. Depending on the cause, there are numerous possible associated anomalies. The most frequent anomalies include central nervous system and spinal anomalies (52%), other musculoskeletal anomalies (28%), and thoracic anomalies (12%).7Nemec U. Nemec S.F. Kasprian G. et al.Clubfeet and associated abnormalities on fetal magnetic resonance imaging.Prenat Diagn. 2012; 32: 822-828PubMed Google Scholar The differential diagnosis of clubfoot is extensive. Clubfoot can be caused by both extrinsic and intrinsic causes. Extrinsic factors that can affect fetal foot position in utero include oligohydramnios, breech presentation, Müllerian anomalies, multiple gestation, amniotic band sequence, or amniocentesis at <15 weeks of gestation.1Werler M.M. Yazdy M.M. Mitchell A.A. et al.Descriptive epidemiology of idiopathic clubfoot.Am J Med Genet A. 2013; 161A: 1569-1578Crossref PubMed Scopus (63) Google Scholar,2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar,11Benacerraf B.R. Frigoletto F.D. Prenatal ultrasound diagnosis of clubfoot.Radiology. 1985; 155: 211-213Crossref PubMed Scopus (23) Google Scholar,13Lauson S. Alvarez C. Patel M.S. Langlois S. Outcome of prenatally diagnosed isolated clubfoot.Ultrasound Obstet Gynecol. 2010; 35: 708-714PubMed Google Scholar,14Barker S. Chesney D. Miedzybrodzka Z. Maffulli N. Genetics and epidemiology of idiopathic congenital talipes equinovarus.J Pediatr Orthop. 2003; 23: 265-272Crossref PubMed Google Scholar Intrinsic factors (8Bar-Hava I. Bronshtein M. Orvieto R. Shalev Y. Stal S. Ben-Rafael Z. Caution: prenatal clubfoot can be both a transient and a late-onset phenomenon.Prenat Diagn. 1997; 17: 457-460Crossref PubMed Scopus (30) Google Scholar,13Lauson S. Alvarez C. Patel M.S. Langlois S. Outcome of prenatally diagnosed isolated clubfoot.Ultrasound Obstet Gynecol. 2010; 35: 708-714PubMed Google Scholar,15Bacino C.A. Hecht J.T. Etiopathogenesis of equinovarus foot malformations.Eur J Med Genet. 2014; 57: 473-479Crossref PubMed Scopus (28) Google Scholar, 16Basit S. Khoshhal K.I. Genetics of clubfoot; recent progress and future perspectives.Eur J Med Genet. 2018; 61: 107-113Crossref PubMed Scopus (34) Google Scholar, 17Martin S. Clubfoot (Talipes equinovarus).in: Joshua A. Copel M.E.D.A. Feltovich Helen Obstetric imaging: fetal diagnosis and care. Elsevier, Philadelphia2018: 308-310Crossref Scopus (0) Google Scholar) include the following causes:•Chromosome abnormalities (30% complex, 2% isolated), including trisomy 18, 13, 21; 4p, 18q, and 22q11.2 deletion syndromes; sex chromosome abnormalities; microdeletions; or duplications3Viaris de le Segno B. Gruchy N. Bronfen C. et al.Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center.J Clin Ultrasound. 2016; 44: 100-105Crossref PubMed Scopus (15) Google Scholar,13Lauson S. Alvarez C. Patel M.S. Langlois S. Outcome of prenatally diagnosed isolated clubfoot.Ultrasound Obstet Gynecol. 2010; 35: 708-714PubMed Google Scholar,18Shaffer L.G. Rosenfeld J.A. Dabell M.P. et al.Detection rates of clinically significant genomic alterations by microarray analysis for specific anomalies detected by ultrasound.Prenat Diagn. 2012; 32: 986-995Crossref PubMed Scopus (193) Google Scholar,19Cheung K.W. Lai C.W.S. Mak C.C.Y. Hui P.W. Chung B.H.Y. Kan A.S.Y. A case of prenatal isolated talipes and 22q11.2 deletion syndrome-an important chromosomal disorder missed by noninvasive prenatal screening.Prenat Diagn. 2018; 38: 376-378Crossref PubMed Scopus (6) Google Scholar•Genetic syndromes such as Larsen; Gordon; Pierre-Robin; Pena-Shokeir; Meckel-Gruber; Smith-Lemli-Opitz; Roberts; TARP (Talipes equinovarus, Atrial septal defect, Robin sequence, Persistence of left superior vena cava); and Lambert, among others•Skeletal dysplasias such as Ellis van Creveld syndrome, diastrophic dysplasia, chondrodysplasia punctata, camptomelic dysplasia, atelosteogenesis, and mesomelic dysplasia•Neuromuscular conditions that include arthrogryposis multiplex congenita, myotonic dystrophy, and spinal muscular atrophy•Other neurologic abnormalities such as neural tube defects, holoprosencephaly, and hydranencephaly Diagnostic testing (amniocentesis or chorionic villus sampling) with chromosomal microarray analysis (CMA) should be offered when a club foot is detected.2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar If ultrasound findings or screening test results are suggestive of a common aneuploidy, it is reasonable initially to perform karyotype analysis or fluorescence in situ hybridization, with reflex to CMA if these test results are normal. If there are additional anomalies, consanguinity, or a family history of a specific condition, gene panel testing or exome sequencing may be useful because CMA does not detect single-gene (Mendelian) disorders. If exome sequencing is pursued, appropriate pretest and posttest genetic counseling by a provider who is experienced in the complexities of genomic sequencing is recommended.20International Society for Prenatal Diagnosis, Society for Maternal Fetal Medicine, Perinatal Quality FoundationJoint Position Statement from the International Society for Prenatal Diagnosis (ISPD), the Society for Maternal Fetal Medicine (SMFM), and the Perinatal Quality Foundation (PQF) on the use of genome-wide sequencing for fetal diagnosis.Prenat Diagn. 2018; 38: 6-9Crossref PubMed Scopus (121) Google Scholar After appropriate counseling, cell-free DNA screening is an option for patients who decline diagnostic evaluation if a common aneuploidy is suspected. A detailed ultrasound examination should be performed with attention to other joints to assess for arthrogryposis multiplex congenita. Examination should also include comprehensive imaging of the intracranial structures (eg, a neurosonogram) and the fetal heart. A fetal echocardiogram and fetal magnetic resonance imaging should be considered if cardiac or central nervous system abnormalities or a syndromic cause is suspected. Magnetic resonance imaging has been reported to improve the detection of associated anomalies in complex, but not isolated, cases.7Nemec U. Nemec S.F. Kasprian G. et al.Clubfeet and associated abnormalities on fetal magnetic resonance imaging.Prenat Diagn. 2012; 32: 822-828PubMed Google Scholar Pregnancy termination is an option that should be discussed with all patients in whom a fetal anomaly is detected. Shared patient decision-making requires a thorough evaluation and multidisciplinary counseling regarding prognosis. The specific finding of clubfoot does not generally affect delivery management, although delivery at a tertiary care center with pediatric genetic and orthopedic surgery consultation may be appropriate with additional clinical findings. Management of complex cases depends on the constellation of anomalies. Mode of delivery is based on usual obstetric indications. The prognosis depends on associated conditions but is generally excellent for isolated clubfoot. Perinatal death and neurodevelopmental and musculoskeletal issues are more likely with complex cases.4Bakalis S. Sairam S. Homfray T. Harrington K. Nicolaides K. Thilaganathan B. Outcome of antenatally diagnosed talipes equinovarus in an unselected obstetric population.Ultrasound Obstet Gynecol. 2002; 20: 226-229Crossref PubMed Scopus (50) Google Scholar Families should be referred to pediatric orthopedics for evaluation for postnatal treatment. The current usual approach to therapy is the Ponseti method, which involves foot manipulation, serial casting, bracing, and monitoring for and treatment of relapse if it occurs.21Radler C. The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations.Int Orthop. 2013; 37: 1747-1753Crossref PubMed Scopus (76) Google Scholar Estimates for cases that require postnatal surgical intervention have been reported to range from 12–50%, although surgical treatment has been decreasing with time.2Sharon-Weiner M. Sukenik-Halevy R. Tepper R. Fishman A. Biron-Shental T. Markovitch O. Diagnostic accuracy, work-up, and outcomes of pregnancies with clubfoot detected by prenatal sonography.Prenat Diagn. 2017; 37: 754-763Crossref PubMed Scopus (17) Google Scholar,5Canto M.J. Cano S. Palau J. Ojeda F. Prenatal diagnosis of clubfoot in low-risk population: associated anomalies and long-term outcome.Prenat Diagn. 2008; 28: 343-346Crossref PubMed Scopus (32) Google Scholar,22Zionts L.E. Zhao G. Hitchcock K. Maewal J. Ebramzadeh E. Has the rate of extensive surgery to treat idiopathic clubfoot declined in the United States?.J Bone Joint Surg Am. 2010; 92: 882-889Crossref PubMed Scopus (81) Google Scholar Clubfoot is a common congenital malformation of the foot and ankle. It can involve one or both feet and can be an isolated finding or associated with other anomalies. Diagnosis should include a detailed ultrasound examination to look for associated anomalies and genetic counseling and diagnostic testing. Timing and route for labor and delivery are not altered for isolated cases. Prognosis depends on associated conditions and underlying genetic abnormalities, but the majority of cases can be corrected with manipulation and serial casting postnatally.