Do Diabetic Foot Ulcer Segmentation Models Generalize? A Cross-Dataset Benchmark of CNN and Transformer Architectures
Deep learning models for diabetic foot ulcer (DFU) segmentation routinely report high accuracy, but they are almost always trained and tested on the same dataset, leaving their behaviour on data from a different clinical source largely unmeasured. We benchmark three representative segmentation architectures -- U-Net and DeepLabV3+ (convolutional) and SegFormer-B2 (Transformer) -- under an identical, leakage-screened protocol: training on the combined FUSeg/AZH wound data and evaluating, without fine-tuning, on two independent external datasets (DFUC2022 and Medetec). All models achieve strong in-domain performance (Dice 0.80--0.83) but degrade substantially across datasets. The degradation is, however, architecture-dependent: SegFormer-B2 generalizes best on both external sets (DFUC2022 Dice 0.557, Medetec Dice 0.786), outperforming both convolutional models, while the more complex DeepLabV3+ generalizes worse than the simpler U-Net. Per-image failure analysis on 2,160 images across both external test sets confirms that SegFormer-B2 produces the fewest catastrophic failures on DFUC2022 (31.1%), compared with U-Net (38.5%) and DeepLabV3+ (43.0%). The consistent ranking across two independent external sources, confirmed by Wilcoxon signed-rank tests (p < 0.001 on both datasets), indicates that architecture family, not model complexity, drives cross-hospital generalization.