Background: Venous thromboembolism (VTE) remains a leading preventable cause of perioperative mortality following total joint arthroplasty (TJA). The historically low perceived VTE incidence in Asian populations has been progressively dismantled by systematic screening studies. Emerging evidence demonstrates that Indian (South Asian) patients carry thrombotic risk comparable to Western cohorts, while East Asian patients demonstrate a genetically distinct thrombophilic phenotype. Concurrently, rapidly expanding arthroplasty volumes in India and China have substantially increased aggregate surgical VTE risk in both nations. Objectives: This narrative review critically examines the epidemiology, pathomechanisms, and pharmacological management of postoperative VTE in Indian and Chinese orthopedic patient populations; evaluates infrastructure and economic barriers to mechanical prophylaxis implementation; and identifies priority areas for development of Asian-specific risk stratification tools. Methods: A structured narrative review was conducted across PubMed/MEDLINE, Embase, and CENTRAL (1990–March 2025), targeting VTE epidemiology in Asian orthopedic patients, comparative pharmacological prophylaxis trials, mechanical prophylaxis barriers, and risk assessment model validation in Indian and Chinese populations. Evidence quality was assessed using GRADE-informed reasoning. Large RCTs and meta-analyses were prioritized in the pharmacological comparisons. Results: Screening-detected DVT rates of 27–40% in Asian TJA patients contrast with symptomatic event rates below 1%, confirming diagnostic underdetection rather than genuine biological protection underlies historical low VTE estimates. South Asian patients lack the protective East Asian thrombophilic phenotype and carry VTE risk comparable to Whites. Apixaban has the most favorable safety-efficacy profile among DOACs (bleeding RR 0.89 vs LMWH; DVT OR 0.42 vs enoxaparin in Asian TKA meta-analysis). Rivaroxaban significantly increases hidden blood loss unless combined with tranexamic acid. No validated Asian-specific risk assessment model for TJA exists. Conclusions: Prophylaxis protocols derived from Western evidence cannot be uniformly applied to Indian and Chinese orthopedic patients. Development of prospectively validated Asian-specific predictive nomograms incorporating ERAS context and distinct South Asian versus East Asian thrombophilic phenotypes is the most urgent unmet need in this field.