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Modification of the titanium (Ti) surface is widely known to influence biological reactions such as protein adsorption and bacterial adhesion in vivo, ultimately controlling osseointegration. In this study, we sought to investigate the correlation of protein adsorption and bacterial adhesion with the nanoporous structure of acid-alkali-treated Ti implants, shedding light on the modification of Ti implants to promote osseointegration. We fabricated nontreated porous Ti (NTPT) by powder metallurgy and immersed it in mixed acids and NaOH to obtain acid-alkali-treated porous Ti (AAPT). Nontreated dense sample (NTDT) served as control. Our results showed that nanopores were formed after acid-alkali treatment. AAPT showed a higher specific surface area and became much more hydrophilic than NTPT and NTDT (p < 0.001). Compared to dense samples, porous samples exhibited a lower zeta potential and higher adsorbed protein level at each time point within 120 min (p < 0.001). AAPT formed a thicker protein layer by serum precoating than NTPT and NTDT (p < 0.001). The main adsorbed proteins on AAPT and NTPT were albumin, α1 antitrypsin, transferrin, apolipoprotein A1, complement C3 and haptoglobin α1 chain. The amounts of bacteria adhering to the serum-precoated samples were lower than those adhering to the nonprecoated samples (p < 0.05). Lower-molecular-weight proteins showed higher affinity to porous Ti. In conclusion, acid-alkali treatment facilitated protein adsorption by porous Ti, and the protein coating tended to prevent bacteria from adhering. These findings may be utilized for Ti implant modification aimed at reducing bacterial adhesion and enhancing osseointegration. [ABSTRACT FROM AUTHOR]